Job description
Appeals Claims Analyst (Troy, MI)
Summary
Process Predeterminations, Medical Review inquiries and Member/Provider Appeals. Investigate requests, make decisions where appropriate, correspond with Members and their Attorneys, Trustees, Plan Professionals and Plan Managers with respect to open cases. Follow Plan guidelines with respect to specific policies and procedures.
Essential Duties and Responsibilities include but not limited to
- Review Predetermination requests received for compliance of plan benefits and medical necessity.
- Review plan benefits for coverage limitations and benefit coverage, advise Claim Analyst, Member and Plan Manager of determination as appropriate.
- Review and prepare Member/Provider appeals for review by Fund Board of Trustees. Communicate with Plan Professionals, Claim Management, Claim Analysts, and Plan Admin team.
- Take calls from providers, members, Claim staff, client representatives and off-site offices.
- Answers inquiries pertaining to specific cases as well as Industry standards.
- Track all activity, follow up as required, and send reports to Plan Managers, Claim Management team as necessary.
- Review SPD and SMM drafts, Network benefit summaries, Internal processing notes and BIB’s for accuracy/compliance.
- Other duties as assigned.
- Regular and predictable attendance is an essential function of this job.
Supervisory Responsibilities No supervisory responsibilities
Qualifications To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Individual must have previous medical claims processing experience and knowledgeable of medical terminology. i.e. CPT codes, ICD-10 codes, HCPCS, ADA codes. Analyst must be methodical and possess the skills to determine approval for benefit payment, versus pending or denying. Analyst will be accountable for benefit determinations.
Education and/or Experience High School diploma or GED equivalent and 5 years related experience. Knowledge of medical and dental claims processing. Knowledge of medical terminology.
Language Skills Ability to read and interpret documents such as Summary Plan Descriptions of Plan rules. Ability to communicate professionally and clearly with other departments of BeneSys.
Mathematical Skills Ability to apply concepts of basic addition, subtraction, multiplication and division.
Reasoning Skills Ability to apply common sense to carry out detailed written or oral instructions.
Certificates, Licenses, Registrations None required.
Physical Demands The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Work Environment The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Work Schedule
Full time. Monday - Friday. 8:00am - 4:30pm. Permanent Work From Home (No in-office days).
Competitive Benefits & Compensation Package
- Paid Time Off (PTO)
- 15 days of PTO during the next calendar year!
- Medical, dental, vision, and life insurance
- Company paid short term disability, long term disability, and AD&D insurance
- 401k with employer match
- Tuition reimbursement program
- Career development opportunities
- Referral bonus for all full-time referrals
- Competitive wages
- Annual opportunities for increases and bonuses
Pay
Hourly rate for this position ranges from $22.00 - $25.00 per hour. Starting rate dependent on skills, experience, education, location and other business factors.
Our Culture
BeneSys wants to be a great service provider to the members we serve and we recognize we can only do that if we are also a great employer with successful employees. In short, our success is driven by our employees successes. We want to be a place people want to work, feel proud of what they do and feel fulfilled both professionally and personally; creating a place where employees can find long-term growth and potential.
Our culture focuses on three core values:
- Collaboration: working together across 31 locations to achieve the best for the company and our clients
- Dedication: striving to create an environment where all employees work toward a common goal while committing to providing the best customer service to our members and our colleagues
- Integrity: doing what we say we will do. Upholding strong ethical and moral principles
ADA & EEO
Reasonable accommodations will be made so that qualified individuals with disabilities are able to complete the application process and, if hired, fulfill the essential functions of their job.
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